Systematic overview of systematic reviews and clinical guidelines: assessment and prevention of behavioural risk factors associated with oral cancer to inform dental professionals in primary care dental practices.

Aims/objectives Tobacco and alcohol are recognised as the major modifiable risk factors for oral cancer, the incidence of which is rising globally and predicted to increase. This paper aimed to: 1) appraise and synthesise best practice evidence for assessing the major behavioural risk factors for oral cancer and delivering behaviour change interventions (for example, advice, counselling, signposting/referral to preventive services); and 2) assess appropriateness for implementation by dental professionals in primary care.Methods A systematic overview was undertaken of systematic reviews and international clinical guidelines. This involved: systematically searching and collating the international literature on assessing oral cancer risk and delivering preventive interventions within primary care; quality appraising and assessing the risk of bias using validated tools; synthesising the evidence for best practice; and assessing application of key findings to the dental setting.Results and conclusions There is clear evidence for the effectiveness of a 'brief', in-person, motivational intervention for sustained tobacco abstinence or reduced alcohol consumption, following risk factor assessment. Evidence for combined behavioural interventions is lacking. There is no firm conclusion with regards to optimal duration of brief interventions (range 5-20 minutes). For tobacco users, longer (10-20 minutes) and intensive (more than 20 minutes, with follow-up visits) interventions are more effective in increasing quit rates compared to no intervention; very brief (less than five minutes) interventions in a single session show comparable effectiveness to the longer/more intensive interventions. For alcohol users, 10-15-minute multi-contact interventions were most effective, compared to no intervention or very brief (less than five minutes) intervention or intensive intervention; brief interventions of five-minute duration were equally effective. There is limited direct evidence from the dental practice setting (one high-quality systematic review relating to tobacco prevention and none relating to alcohol). Thus, very brief, or brief advice of up to five minutes, should be trialled for tobacco and alcohol respectively in a dental practice setting, after risk assessment tailored to patient motivational status. Exploring delivery by the dental team is supported, as effectiveness was generally independent of primary care provider.

Oral diseases: a global public health challenge.

Oral diseases are among the most prevalent diseases globally and have serious health and economic burdens, greatly reducing quality of life for those affected. The most prevalent and consequential oral diseases globally are dental caries (tooth decay), periodontal disease, tooth loss, and cancers of the lips and oral cavity. In this first of two papers in a Series on oral health, we describe the scope of the global oral disease epidemic, its origins in terms of social and commercial determinants, and its costs in terms of population wellbeing and societal impact. Although oral diseases are largely preventable, they persist with high prevalence, reflecting widespread social and economic inequalities and inadequate funding for prevention and treatment, particularly in low-income and middle-income countries (LMICs). As with most non-communicable diseases (NCDs), oral conditions are chronic and strongly socially patterned. Children living in poverty, socially marginalised groups, and older people are the most affected by oral diseases, and have poor access to dental care. In many LMICs, oral diseases remain largely untreated because the treatment costs exceed available resources. The personal consequences of chronic untreated oral diseases are often severe and can include unremitting pain, sepsis, reduced quality of life, lost school days, disruption to family life, and decreased work productivity. The costs of treating oral diseases impose large economic burdens to families and health-care systems. Oral diseases are undoubtedly a global public health problem, with particular concern over their rising prevalence in many LMICs linked to wider social, economic, and commercial changes. By describing the extent and consequences of oral diseases, their social and commercial determinants, and their ongoing neglect in global health policy, we aim to highlight the urgent need to address oral diseases among other NCDs as a global health priority.

Ending the neglect of global oral health: time for radical action.

Oral diseases are a major global public health problem affecting over 3·5 billion people. However, dentistry has so far been unable to tackle this problem. A fundamentally different approach is now needed. In this second of two papers in a Series on oral health, we present a critique of dentistry, highlighting its key limitations and the urgent need for system reform. In high-income countries, the current treatment-dominated, increasingly high-technology, interventionist, and specialised approach is not tackling the underlying causes of disease and is not addressing inequalities in oral health. In low-income and middle-income countries (LMICs), the limitations of so-called westernised dentistry are at their most acute; dentistry is often unavailable, unaffordable, and inappropriate for the majority of these populations, but particularly the rural poor. Rather than being isolated and separated from the mainstream health-care system, dentistry needs to be more integrated, in particular with primary care services. The global drive for universal health coverage provides an ideal opportunity for this integration. Dental care systems should focus more on promoting and maintaining oral health and achieving greater oral health equity. Sugar, alcohol, and tobacco consumption, and their underlying social and commercial determinants, are common risk factors shared with a range of other non-communicable diseases (NCDs). Coherent and comprehensive regulation and legislation are needed to tackle these shared risk factors. In this Series paper, we focus on the need to reduce sugar consumption and describe how this can be achieved through the adoption of a range of upstream policies designed to combat the corporate strategies used by the global sugar industry to promote sugar consumption and profits. At present, the sugar industry is influencing dental research, oral health policy, and professional organisations through its well developed corporate strategies. The development of clearer and more transparent conflict of interest policies and procedures to limit and clarify the influence of the sugar industry on research, policy, and practice is needed. Combating the commercial determinants of oral diseases and other NCDs should be a major policy priority.

Assessment and prevention of behavioural and social risk factors associated with oral cancer: protocol for a systematic review of clinical guidelines and systematic reviews to inform Primary Care dental professionals.

BACKGROUND: Tobacco and alcohol are recognised as the major risk factors for both oral cavity (mouth) and oropharyngeal (throat) cancers, with increasing acceptance of the role of human papillomavirus (HPV) in the aetiology of oropharyngeal cancers. In addition, there is a significant increased risk for oral cancer among lower socioeconomic groups, males and older age groups. There is a growing evidence for the potential role of primary care professionals in smoking cessation and reducing alcohol-related harm. However, there are uncertainties about the best approaches/strategies to assess risk factors associated with oral cancer, effective components of preventive interventions for behaviour change and implementation strategies in primary care dental settings. Thus, in order to contribute to the prevention of oral cancer effectively, dental professionals need to assess patients on the major risk factors (tobacco, alcohol and HPV/sexual behaviours) and deliver appropriate prevention, taking into account the patient's sociodemographic context. AIM: The study aims to synthesise evidence on the best practice for undertaking an assessment of major behavioural risk factors associated with oral cancer and delivering effective behaviour change preventive interventions (e.g. advice, counselling, patient recall, signposting/referral to preventive services) by dental professionals in primary care dental settings. METHOD: The study involves a systematic review and evidence appraisal. We will search for clinical guidelines and systematic reviews from the following databases: Cochrane Library, Ovid MEDLINE, EMBASE, Web of Science, PsychINFO, PubMed, TRIP and Google Scholar. We will also search websites of professional organisations/agencies and bibliographies/reference lists of selected papers. Quality will be assessed with the AGREE II (Appraisal of Guidelines for Research & Evaluation II) instrument for included clinical guidelines and the AMSTAR (A Measurement Tool to Assess Systematic Reviews) and ROBIS instruments for included systematic reviews. The best practice evidence will be assessed via a narrative synthesis of extracted data, considering publication quality. DISCUSSION: This systematic review will synthesise evidence on the best practice for oral cancer risk factor assessment and prevention and evaluate the relationship between available clinical guidelines and the review evidence base. This collation of evidence will be useful for making recommendations for future intervention, research and guideline development. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015025289.

Estimating and explaining the effect of education and income on head and neck cancer risk: INHANCE consortium pooled analysis of 31 case-control studies from 27 countries.

Low socioeconomic status has been reported to be associated with head and neck cancer risk. However, previous studies have been too small to examine the associations by cancer subsite, age, sex, global region and calendar time and to explain the association in terms of behavioral risk factors. Individual participant data of 23,964 cases with head and neck cancer and 31,954 controls from 31 studies in 27 countries pooled with random effects models. Overall, low education was associated with an increased risk of head and neck cancer (OR = 2.50; 95% CI = 2.02 - 3.09). Overall one-third of the increased risk was not explained by differences in the distribution of cigarette smoking and alcohol behaviors; and it remained elevated among never users of tobacco and nondrinkers (OR = 1.61; 95% CI = 1.13 - 2.31). More of the estimated education effect was not explained by cigarette smoking and alcohol behaviors: in women than in men, in older than younger groups, in the oropharynx than in other sites, in South/Central America than in Europe/North America and was strongest in countries with greater income inequality. Similar findings were observed for the estimated effect of low versus high household income. The lowest levels of income and educational attainment were associated with more than 2-fold increased risk of head and neck cancer, which is not entirely explained by differences in the distributions of behavioral risk factors for these cancers and which varies across cancer sites, sexes, countries and country income inequality levels.

Developing a new self-reported scale of oral health outcomes for 5-year-old children (SOHO-5).

BACKGROUND: Information on the impact of oral health on quality of life of children younger than 8 years is mostly based on parental reports, as methodological and conceptual challenges have hindered the development of relevant validated self-reported measures. This study aimed to develop and assess the reliability and validity of a new self-reported oral health related quality of life measure, the Scale of Oral Health Outcomes for 5-year-old children (SOHO-5), in the UK. METHODS: A cross-sectional study of two phases. First, consultation focus groups (CFGs) with parents of 5-year-olds and review by experts informed the development of the SOHO-5 questionnaire. The second phase assessed its reliability and validity on a sample of grade 1 (5-year-old) primary schoolchildren in the Greater Glasgow and Clyde area, Scotland. Data were linked to available clinical oral health information and analysis involved associations of SOHO-5 with subjective and clinical outcomes. RESULTS: CFGs identified eating, drinking, appearance, sleeping, smiling, and socialising as the key oral impacts at this age. 332 children participated in the main study and for 296 (55% girls, mean d3mft: 1.3) clinical data were available. Overall, 49.0% reported at least one oral impact on their daily life. The most prevalent impacts were difficulty eating (28.7%), difficulty sleeping (18.5%), avoiding smiling due to toothache (14.9%) and avoiding smiling due to appearance (12.5%). The questionnaire was quick to administer, with very good comprehension levels. Cronbach's alpha was 0.74 and item-total correlation coefficients ranged between 0.30 and 0.60, demonstrating the internal consistency of the new measure. For validity, SOHO-5 scores were significantly associated with different subjective oral health outcomes (current toothache, toothache lifetime experience, satisfaction with teeth, presence of oral cavities) and an aggregate measure of clinical and subjective oral health outcomes. The new measure also discriminated between different clinical groups in relation to active caries, pulp involvement, and dental sepsis. CONCLUSIONS: This is the first study to develop and validate a self-reported oral health related quality of life measure for 5-year-old children. Initial reliability and validity findings were very satisfactory. SOHO-5 can be a useful tool in clinical studies and public health programs.

Tackling socially determined dental inequalities: ethical aspects of Childsmile, the national child oral health demonstration programme in Scotland.

Many ethical issues are posed by public health interventions. Although abstract theorizing about these issues can be useful, it is the application of ethical theory to real cases which will ultimately be of benefit in decision-making. To this end, this paper will analyse the ethical issues involved in Childsmile, a national oral health demonstration programme in Scotland that aims to improve the oral health of the nation's children and reduce dental inequalities through a combination of targeted and universal interventions. With Scotland's level of dental caries among the worst in Europe, Childsmile represents one of the largest programmes of work aimed at combating oral health inequalities in the UK. The areas of ethical interest include several contrasting themes: reducing health inequalities and improving health; universal and targeted interventions; political values and evidence base; prevention and treatment; and underlying all of these, justice and utility.

Socioeconomic inequalities and oral cancer risk: a systematic review and meta-analysis of case-control studies.

There is uncertainty and limited recognition of the relationship between socioeconomic inequalities and oral cancer. We aimed to quantitatively assess the association between socioeconomic status (SES) and oral cancer incidence risk. A systematic review of case-control studies obtained published and unpublished estimates of the SES risk related to oral cancer. Studies were included which reported odds ratios (ORs) and corresponding 95% CIs of oral cancer with respect to SES, or if the estimates could be calculated or obtained. Meta-analyses were performed on subgroups: SES measure, age, sex, global region, development level, time-period and lifestyle factor adjustments; while sensitivity analyses were conducted based on study methodological issues. Forty-one studies provided 15,344 cases and 33,852 controls which met our inclusion criteria. Compared with individuals who were in high SES strata, the pooled ORs for the risk of developing oral cancer were 1.85 (95%CI 1.60, 2.15; n = 37 studies) for those with low educational attainment; 1.84 (1.47, 2.31; n = 14) for those with low occupational social class; and 2.41 (1.59, 3.65; n = 5) for those with low income. Subgroup analyses showed that low SES was significantly associated with increased oral cancer risk in high and lower income-countries, across the world, and remained when adjusting for potential behavioural confounders. Inequalities persist but are perhaps reducing over recent decades. Oral cancer risk associated with low SES is significant and comparable to lifestyle risk factors. Our results provide evidence to steer health policy which focus on lifestyles factors toward an integrated approach incorporating measures designed to tackle the root causes of disadvantage.

A randomised controlled trial of a smoking cessation intervention delivered by dental hygienists: a feasibility study.

BACKGROUND: Tobacco use continues to be a global public health problem. Helping patients to quit is part of the preventive role of all health professionals. There is now increasing interest in the role that the dental team can play in helping their patients to quit smoking. The aim of this study was to determine the feasibility of undertaking a randomised controlled smoking cessation intervention, utilising dental hygienists to deliver tobacco cessation advice to a cohort of periodontal patients. METHODS: One hundred and eighteen patients who attended consultant clinics in an outpatient dental hospital department (Periodontology) were recruited into a trial. Data were available for 116 participants, 59 intervention and 57 control, and were analysed on an intention-to-treat basis. The intervention group received smoking cessation advice based on the 5As (ask, advise, assess, assist, arrange follow-up) and were offered nicotine replacement therapy (NRT), whereas the control group received 'usual care'. Outcome measures included self-reported smoking cessation, verified by salivary cotinine measurement and CO measurements. Self-reported measures in those trial participants who did not quit included number and length of quit attempts and reduction in smoking. RESULTS: At 3 months, 9/59 (15%) of the intervention group had quit compared to 5/57 (9%) of the controls. At 6 months, 6/59 (10%) of the intervention group quit compared to 3/57 (5%) of the controls. At one year, there were 4/59 (7%) intervention quitters, compared to 2/59 (4%) control quitters. In participants who described themselves as smokers, at 3 and 6 months, a statistically higher percentage of intervention participants reported that they had had a quit attempt of at least one week in the preceding 3 months (37% and 47%, for the intervention group respectively, compared with 18% and 16% for the control group). CONCLUSION: This study has shown the potential that trained dental hygienists could have in delivering smoking cessation advice. While success may be modest, public health gain would indicate that the dental team should participate in this activity. However, to add to the knowledge-base, a multi-centred randomised controlled trial, utilising biochemical verification would be required to be undertaken.

Effect of smoking on serum RANKL and OPG in sex, age and clinically matched supportive-therapy periodontitis patients.

METHODS: The serum concentrations of receptor activator of nuclear factor kappaB ligand (RANKL) and osteoprotegerin (OPG) in age- and sex-matched groups of smokers and non-smokers with almost identical levels of periodontal disease were determined by an enzyme-linked immunosorbent assay (ELISA). We ensured that the 35 smokers were gender, age and clinically matched with a group of 35 non-smokers (confirmed by cotinine immunoassay) from the same population of maintained patients with susceptibility to periodontitis. RESULTS: Cigarette smoker patients tended to have lower serum concentrations of RANKL and OPG than non-smoker patients. While no statistically significant difference was observed for RANKL, there were significant differences in the median serum concentration of OPG (smokers 23.76 pM, non-smokers 59.28 pM) and the ratio of serum concentrations of RANKL and OPG. Concentrations of OPG in the smoker patients also had a statistically significant negative correlation with tobacco consumption. CONCLUSION: Bone loss in smoker-related periodontitis patients may be partially explained by suppression of OPG production.

Oral cancer: prevention and detection in primary dental healthcare.

The incidence of oral cancer is rising in the UK. Mortality from the disease remains high and survival has not improved significantly in the last 30 years. The primary dental health team has an integral role in the delivery of oral health promotion and prevention advice and in the early detection of oral malignancy and potentially malignant lesions. Both prevention and early detection within the general dental practice setting have a potential impact on overall incidence, morbidity and mortality from oral cancer. This paper details the primary dental healthcare team's roles in delivering smoking cessation and alcohol reduction counselling, in the early detection by oral examination, and in the process of prompt referral.